Request to Self-Quarantine/Self-Isolate Off-Campus
You may request to self-quarantine or self-isolate offcampus IF 1) you can self-drive to your location without making any stops(including no stops for gas, bathroom, or food), OR 2) a parent or guardianwill drive you to a location without making any stops. No approvals willbe granted for travel by air, train, or other form of publictransportation. Please complete this form to request permission toself-quarantine/self-isolate off campus/at home. (ie- self-quarantine=closecontact; self-isolation=positive COVD-19 test)
Student ID #
2021-2022 Housing Address (off-campus street address and unit # OR on-campus building, room/apt #)
Address where you would like to quarantine/isolate
Street, City, State
This is my permanent home address
This is a family member's home
This is a non-family member's home
Name of emergency contact
Emergency contact phone number
According to Student Health Services, what dates are you required to be in quarantine/isolation?
Additional comments that will assist with our review of your request, including how you will travel to this location, etc.
I understand that upon approvalof my request I will be required to either: Quarantine at theabove address after being identified as a close contact to someone who testedpositive for Covid. Quarantine is for a minimum of 10 days from last exposurewith a test at home as soon as symptoms develop or at day 7 if symptoms do notoccur. I will also be required to submit a negative covid test, taken on day 7,with a documented date and name for test being done (cannot be over thecounter, take at home), prior to my return. This will be submitted to firstname.lastname@example.org. or Isolate at theabove address for a minimum of 10 days from the onset of symptoms, or date ofpositive test. I understand that I need to communicate with my professorsregarding my absences from classes.
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